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25-year-old female who fell down the stairs, now cannot bear weight and has obvious deformity to her ankle
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28-year-old male with 2 weeks of isolated low back pain and no radicular symptoms
15-year-old female with 2 weeks of atraumatic right distal thigh pain that wakes her from sleep
68-year-old male with 1 month of right knee medial joint line pain that’s worse with activity
64-year-old female with acute onset right shoulder pain and difficulty with overhead activities after a fall
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The first line of treatment for low back pain should be nonpharmacologic and include home exercise along with a gradual resumption of normal activities. Low back pain is now the leading cause of disability worldwide and spans all age groups and socioeconomic statuses. Most patients with low back pain should recover quickly and uneventfully. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. For this reason, initial workup in patients without concerning symptoms should be nonpharmacologic and include home exercise and gradual return to function. Most guidelines now recommend the prudent use of medication, imaging, and surgery. However, globally, gaps between evidence and practice exist with an inappropriately high use of imaging, opioids, and spinal injections. Lumbar spine radiographs should not be obtained upon initial evaluation in those patients without red flag symptoms or symptoms lasting <1 month. Foster et al, review the prevention and treatment of low back pain. They report on the need for a biopsychosocial model in which lab tests and imaging should not be routinely used as part of early treatment. They conclude that we should focus on reducing unnecessary health care for low back pain and supporting patients in remaining active and working. Hartvigsen et al, review what low back pain is and why we as a healthcare community should pay attention. They report that isolated back pain is a combination of numerous factors including biophysical, social, psychological, and genetic that are handled differently among patients. Additionally, they report that imaging findings in patients with low back pain are also identified in patients without back pain, calling into question the utility of initial imaging in these patients. They conclude that no evidence exists that imaging improves patient outcomes and that the current guidelines consistently recommend against it. Incorrect Answers: Answer 1: Given this patient's traumatic event she would be best evaluated with radiographs upon initial presentation. Answer 3: Night pain in this young patient with distal thigh pain warrants radiographic evaluation to rule out an oncologic process. Answer 4: This patient likely has knee osteoarthritis, which should be initially evaluated radiographically. Answer 5: While this patient may have rotator cuff pathology it is important to also evaluate for a proximal humeral fracture.
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